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Ocular Allergy

Paige Wickner, M.D.

Brigham and Women’s Hospital

Boston, MA

&

Leonard Bielory, M.D

Robert Wood Johnson University Hospital

Rutgers University

Disclosures

• Dr. Leonard Bielory:

- Consultant: Allergan,

Bausch and Lomb

- Clinical Trial: Allergan

• Dr. Paige Wickner:

- No financial

disclosures

- Clinical trial:

Genentech

Case 1

• Cc: Itchy eyes

• HPI: 37 yo female

- Progressively worsening seasonal allergies

- Mid April–mid May extreme ocular itching, congestion, fatigue, sinus headaches

- Poor relief despite cetirizine, loratidine, naphcon A, azelastine nasal spray, fluticasone nasal spray and ketotifen fumarate drops

- Wears contacts while at work as a dentist w/ special glasses to visualize root canals

- Avoids hazelnuts and peaches

3

Case 1 cont:

• PmHx: none

• Shx: hamster at home, nonsmoker

• Fhx: 2 children in good health, brother and

mother with seasonal allergies

• All: NKDA

• Meds: see HPI

Case 1 cont:

• Physical Exam:

Genl- NAD, pleasant, conversant.

VSS-

HEENT-

Eyes- see photo, allergic shiner, no abnormality with lid eversion

OP clear without erythema, edema or mucositis, neck supple with no LAD.

Nares patent, moderate turbinate swelling bl and copious clear rhinorrhea

CV- RRR, no m/r/g

Resp- CTA, no ronchi/rales, wheezing

Abd- soft, NT, ND, no HSM

Extr- No clubbing/cyanosis or edema

Skin- areas of dryness with faint erythema in antecubtial fossae bl

Photo courtesy of Dr. Michael Raizman

http://www.biographixmedia.com/human/eye-anatomy.html

Differential Dx of the Red Eye

Acne Rosacea

Staphylococcal

Eyelid

Vernal

Keratoconjunctivitis

Atopic

Keratoconjunctivitis

Giant Papillary

Conjunctivitis

Chronic

Seasonal

Perennial

Acute

Allergic

Adenovirus

Viral

Chlamydial

Gonococcal

Bacterial

Parasitic

Fungal

Infectious

Vasculitis

Episcleritis/Scleritis

Pseudotumor

Pemphigus/Pemphigoid

Kawasaki's Disease

Autoimmune

Ataxia- Telangiectasia

AIDS

Immunodeficiency

Contact

Immune

Conjunctival

Dry Eye

Lacrimal Gland Lacrimal Duct

Sarcoid

Autoimmune

Infectious

Uveitis

Intraocular

Location

Case 1 question 1:

• What is the most likely diagnosis for this

patient?

a. seasonal allergic rhinoconjunctivitis

b. perennial allergic rhinoconjunctivitis

c. vernal keratoconjunctivitis

d. atopic keratoconjunctivitis

© 2009 Lippincott Williams & Wilkins, Inc. Published by Lippincott Williams & Wilkins, Inc. 2

A simple and rapid diagnostic algorithm for the detection of ocular allergic diseases. Mantelli, Flavio; Lambiase, Alessandro; Bonini, Stefano Current Opinion in Allergy & Clinical Immunology. 9(5):471-476, October 2009. DOI: 10.1097/ACI.0b013e3283303ea2

Table 1 Diagnostic features for the different forms of allergic conjunctivitis

Origlieri & Bielory. Expert Opin. Emerging Drugs 2009 14

Case 1 question 2

• The major cell involved in the pathogenesis of

allergic conjunctivitis is:

a. eosinophil

b. neutrophil

c. mast cell

d. basophil

JACI 2000

50 million mast cells in the eye

In healthy eye, most in substantia propria

In allergic state, in more superficial layers

Eye rubbing degranulates mast cells

Greiner, 1985

Mast cells

Heparin

PAF

Slide courtesy of Dr. Stephen Foster, MERSI

15 Bielory JACI 2000

Bielory. MSJM. 78 2011.

Case 1 wrap up:

• Skin testing showed positives to:

prick level: weed mix, cat, ragweed, tree,

alternaria, mugwort, oak, birch

intradermal level: grass mix, plantain,

penicillium, dog

• Patient begun injection immunotherapy with

significant improvement in subsequent spring

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Case 2:

• CC: sent from the ophthalmologist for assistance

• HPI: 21 yo male severe eye disease past 2 years.

- Visual acuity has fluctuated

- Extreme pruritus, periorbital rash which has failed to respond to

multiple medications

- Symptoms began in L eye with discharge and a droopy eyelid

- No contact lens use past 9 months.

- Symptoms improve significantly when he is in Boston as opposed to his

home in North Carolina.

• ROS: discomfort, itching, mucoid discharge, redness,

photophobia, dyspnea

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Case 2 cont.

• PMhx:

- eczema- poor sleep due to pruritis

- asthma- poorly controlled on mometasone

furoate and formoterol fumarate dihydrate

(Dulera) with daily albuterol use

- active tobacco use (2 pack years)

- allergic rhinitis- on IT x 9 months to trees, dust

and pollen with outside allergist in NC

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Case 2 cont:

• Shx: Active duty in army in NC x 1.5 years, no pets at home. Has only lived in US.

• Fhx: Mother, sister and grandparents w/ environmental allergies and asthma. Arthritis in mother and grandparents.

• All: NKDA

• Meds: Cyclosporine 100mg QAM/50mg hx x 3-4 months, sirolimus 4mg daily x 3-4 months, cetirizine 10mg BID, monteleukast 10mg daily, triamcinolone 0.1% topical therapy

21

Case 2 cont:

• Physical Exam:

Genl- NAD, pleasant, conversant. Speaks in a manner that seems almost

restricted by facial tighening of skin

HEENT- Eyes: see photos OS: 3+ giant papillae, OS cornea: superficial

punctate keratitis centrally around 2 o’clock, limbal hypertrophy

OP clear without erythema, edema or mucositis, neck supple with no LAD.

Nares patent, mild mucosal irritation and scant clear rhinorrhea

Resp- CTA, no ronchi/rales, wheezing

Skin- eczematous patches behind knees bl and in antecubital fossa. Evidence

of excoriation without superinfection

• Labs/Data:

- IgE 1001, nl CBC, nl PFTs

- ANA negative, SS-A, SSB negative

- Patch test (TRUE test) negative except mild positive to thimerosal

Bielory & Bielory. Advanced Ocular Care, March 2010

Photo courtesy of Dr. Michael Raizman, M.D.

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Case 2 question 1

• Which of the following is an indication to refer to opthalmology?

a. Pain

b. Photophobia

c. Lack of red reflex

d. Initiation of long term steroids

e. All of the above

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Case 2 cont:

• Additional opthalmic medications tried:

alcaftadine, acetylcysteine, elestat, patanol,

cromolyn, bepreve, durezol and predfort

• He has received injections of supratarsal

Kenalog starting Aug 2011

26

Case 2 question 2:

• Which one of these ocular agents is a pure

antihistamine?

a. levocabastine

b. olpatadine

c. ketotifen

d. azelastine

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Table of ocular therapies

Bielory. MSJM 78 2011.

Classification of Conjunctivitis Subtypes: An Update

Pts. With Clin. Signif.

Itching

(n = 194)

Pts. With Clin.

Signif. Dryness

(n = 247)

N = 112

(57.7%)

Approx 60% of patients reporting clinically significant itching also

reported clinically significant dryness Hom MM, Nguyen AL, Bielory L. Ann Allergy Asthma Immunol. 2012;108:163-166.

AC Patients Often Report

Both Ocular Itching and Dryness

Classification of Conjunctivitis Subtypes: An Update

Pts. With Clin.

Signif. Dryness

(n = 247)

Pts. With Clin. Signif.

Itching

(n = 194)

N = 112

(45.3%)

Approx 45% of patients reporting clinically significant dryness

also reported clinically significant itching Hom MM, Nguyen AL, Bielory L. Ann Allergy Asthma Immunol. 2012;108:163-166.

AC Patients Often Report Both Ocular Itching and Dryness

Classification of Conjunctivitis Subtypes: An Update

Pts. With Clin.

Signif. Dryness

(n = 247)

Pts. With Clin. Signif.

Itching

(n = 194)

N = 112

(45.3%)

Hom MM, Nguyen AL, Bielory L. Ann Allergy Asthma Immunol. 2012;108:163-166.

Patients with a history of AC...

•Approx. 40% may report clinically significant

symptom of dryness

•Approx. 60% of patients with clinically significant itch

may also report clinically significant dryness

AC Patients Often Report Both Ocular Itching and Dryness

Photo courtesy of Dr. Michael Raizman

Photo courtesy of Dr. Michael Raizman

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Case 3

• Cc: swollen and red eyes

• HPI: 46 yo female

– Lifelong history of asthma

– Animal dander sensitivities s/p IT in high school

– Significant worsening of periorbital redness and swelling since

delivering her triplets 7 years ago

– Patient has been tried on antihistamines including doxepin and

hydroxyzine, multiple courses of systemic steroids, topical steroids

and local steroid injections without relief of symptoms.

– She feels her symptoms flare around her menstrual cycles

• ROS: pruritus, burning, stinging of eyes, emotional distress

over appearance

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Case 3 cont:

• PmHx:

-PCOS

-Hashimoto’s thyroiditis

-Eczema- see HPI

-Allergic rhinitis- s/p IT to animal dander, mild fall

symptoms

-Asthma- last hospitalization in college, maintained on

advair

-Pre-eclampsia during delivery of triplets

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Case 3 cont:

• Soc Hx: Relocated during her pregnancy. No pets. No

smoking. Works playing the horn.

• Fam Hx:

– three 7-year-old sons with asthma

– mother with RA

– father with eczema, Guillain-Barre syndrome.

• All: NKDA

• Meds: cefadroxil 500 mg b.i.d. (x1 week), CellCept 1500

mg b.i.d. (x3weeks), desoximetasone 0.05% cream as

directed, hydrocortisone butyrate 0.1% b.i.d., hydroxyzine

25 mg to 50 mg at bedtime, and prednisone 20 mg QD,

UV therapy

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Case 3 cont:

• PE notable for:

Eyes- see photos, sclerae anicteric, PERRL, lid inversion normal

Nares patent

Resp- CTA, no ronchi/rales, wheezing

Skin- supra and infraorbital mild edema OU, well demarcated

periorbital erythema

• Labs:

- Chem 20, CPK nl, ANA nl

- CBC with differential unremarkable, absolute eosinophils 520

- IgE 225, remainder of immunoglobulins and SPEP wnl

- HIV negative, flow cytometry normal cell subsets

Used with patients permission, December 2012

Feser et al. BJD 2008 159.

Feser et al. BJD 2008 159.

Photos courtesy of Dr. Michael

Raizman, M.D.

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Case 3: Question 1

• What would you do next?

a. skin test for environmental allergens

b. increase immunosupression

c. patch test

d. skin test for progesterone

hypersensitivity

Patch testing

• Results of patch testing at 96 hours are as follows:

-North American 65 Extended Series: 1 to 2+ carba mix, 1+ balsam of Peru, 1+ nickel, ?bacitracin, ?mixed dialkylthiourea, ?methylchloroisothiazolinone, ?glutaraldehyde, 1+ propylene glycol, 1+ 4-chloro-3,5-xylenol, 1+ iodopropynyl butylcarbamate, 1+ Ylang-Ylang oil.

-Cosmetic Series: 1+ octyl gallate, ?dodecyl gallate.

-Bakery Series: 1+ vanillin.

-Textile Series: No positives.

-Dental Series: No positives.

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Case 2 continued

• SCANNED IN

PRICK/ID results

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Case 2 continued

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Case 3 outcome/follow up

• Started Xolair

• Able to wean off of prednisone

• Continues on cellcept, topical therapies

• Considering starting immunotherapy

although rhinitis symptoms and asthma at

present well controlled